13030149 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10155 ORANGE AVE CONTRACTOR:BELFOR PROPERTY PERMIT NO: 13030.i49
RESTORATION
OWNER'S NAME: JOHN A IMPINK 2297 RINGWOOD AVE DATE ISSUED:03/27/2013
OWNER'S PHONE: 4085069690 SAN JOSE,CA 95133 PHONE NO:(408)929-3473
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL❑ COMMERCIALE]
License Classy_ Lic.# SS 3 REMODEL THROUGH OUT 744 SQ FT,REMOVE AND
REPLAC1 ,��� FURNACE
�^l1(Q7)ate �J �i 3
Contractor � FURNACE AND WATER HEATER,RE-STUCCO 336 SQ FT
1 hereby affirm that I am licensed under the provisions o Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$80000
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this APN Number:35716058.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that 1 have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180;TOM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the 27 /
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signa6� � Date s? All roofs shall be inspected prior to any roofing material being installed.If a roof is
'_ ! installed without first obtaining an inspection,1 agree to remove all new materials for
P g
inspection.
❑ OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&,Professions Code)
1,m owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(x)should I store or handle hazardous
1 have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this —
permit is issued. Owner or authorized age te:
1 certify that in the performance of the work for which this permit is issued,I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must 1 hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
I certify that I have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned.property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
indemnify and.keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
i
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 10155 Oranage Ave DATE: 03/27/2013 REVIEWED BY: Mendez
APN: BP#: 3�3v� `VALUATION: 1$80,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY SFD or Duplex PENTAMATION 1R3SFDREM
USE: PERMIT TYPE:
WORK Remodel through out 744 sq ft remove and replace furnace and water heater, re-stucco 336 sq ft
SCOPE
Mech.Plan Check 0.0 hrs $0.00 Plumb.Plan Check 0.0 hrs $0.00 Elec.Plan Check
Mech.Permit Fee: IMPERMIT Plumb.Permit Fee: IPPERMIT Elec. Permit Fee:
LerOthMech.Insp. 0.0 hrs $45.00 Other Plumb Insp. 0.0 hrs $45.00 Other Elec.Insp.
Insp.Fee: plumb. Insp. Fee: Elee.Insp.-Fee:
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). Thesefees are based on the prelimina information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS free Resolution 11-053 Eff. 7/1/12) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = s.f Remodel,Other
Suppl.PC Fee.: (F) Reg. () OT0.0 hrs $0.00 $534.00 IREMRESOTH
PME Plan Check: $0.00 = # Mechanical
Permit Fee:. $0.00 $133.00 1 1MFR=<100 Furnace,Forced-Air
Supp/. Insp. Fee Reg. OT O,Q hrs $0.00 0 # Plumbing
PME Unit Fee: $0.00 $27.00 1PRWHEATR Water Heater
PME Permit Fee: $90.00 336 s.f. Restucco
Consitztction .Tax. $467.00 1STUCOAPP
Administrative Fee: 1ADMI1v $42.00
Work Without Permit? 0 Yes 0 No $0.00
Advanced Plannine Fee: $0.00 Select a Non-Residential Q
Travel Documentation Fee: ITRA VDOC $45.00 Building or Structure 0
i
Strong Motion Fee: 1BSEISMICR $8.00 Select an Administrative Item .
Bldg Stds Commission Fee: IBCBSC $4.00
SUBTOTALS: F $189.00 $1,161.00 TOTAL FEE: $113"50.00
Revised: 01/01/2013